Mu s: 01/LPTB

(Ban hnh km theo Thng t

s 28/ 2011/TT-BTC ngy
28/02 /2011 ca B Ti chnh)

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

T KHAI L PH TRC B NH, T

[01] K tnh thu: Theo tng ln pht sinh
[02] Ln u

[03] B sung ln th

[04] Tn ngi np thu: .....................................................................................

[05] M s thu: .............................................................................................
[06] a ch: ...................................................................................................
[07] Qun/huyn: ................... [08] Tnh/Thnh ph: .....................................
[09] in thoi: ..................... [10] Fax: .................. [11] Email: ..................
[12] i l thu (nu c) :.....................................................................................
[13] M s thu: .............................................................................................
[14] a ch: ...................................................................................................
[15] Qun/huyn: ................... [16] Tnh/Thnh ph: .....................................
[17] in thoi: ..................... [18] Fax: .................. [19] Email: ..................
[20] Hp ng i l thu, s:.....................................ngy ..................................

C IM NH T:
1. t:
1.1 a ch tha t:
1.2. V tr tha t (mt tin ng ph hay ng, hm):
1.3. Mc ch s dng t:
1.4. Din tch (m2):
1.5. Ngun gc nh t: (t c Nh nc giao, cho thu; t nhn chuyn nhng; nhn tha k, hoc
nhn tng, cho):
a) Tn t chc, c nhn chuyn giao QSD:
a ch ngi giao QSD:
b) Thi im lm giy t chuyn giao QSD ngy.......... thng....... nm............
1.6. Gi tr t thc t chuyn giao (nu c):
2. Nh:
2.1. Cp nh:
Loi nh:
2.2. Din tch nh (m2 sn xy dng):
2.3. Ngun gc nh:
a) T xy dng:
- Nm hon cng (hoc nm bt u s dng nh):
b) Mua, tha k, cho, tng:
- Thi im lm giy t chuyn giao nh: Ngy ............. thng ............ nm..............
2.4. Gi tr nh (ng):
3. Gi tr nh, t thc t nhn chuyn nhng, nhn tha k, nhn tng cho (ng):
4. Ti sn thuc din khng phi np hoc c min l ph trc b (l do):
5. Giy t c lin quan, gm:
Ti cam oan s liu khai trn l ng v chu trch nhim trc php lut v s liu khai./
NHN VIN I L THU

H v tn:
Chng ch hnh ngh s:

Ngy......... thng........... nm..........

NGI NP THU hoc
I DIN HP PHP CA NGI NP THU
K, ghi r h tn, chc v v ng du (nu c)